Hodgson et al.
Critical Care 2013, 17:207
http://ccforum.com/content/17/1/207
REVIEW
Clinical review: Early patient mobilization in the ICU
Carol L Hodgson*1,2, Sue Berney3,4, Megan Harrold5,6, Manoj Saxena7,8,9 and Rinaldo Bellomo1
Abstract
Early mobilization (EM) of ICU patients is a
physiologically logical intervention to attenuate critical
illness-associated muscle weakness. However, its
long-term value remains controversial. We performed
a detailed analytical review of the literature using
multiple relevant key terms in order to provide a
comprehensive assessment of current knowledge
on EM in critically ill patients. We found that the term
EM remains undefined and encompasses a range of
heterogeneous interventions that have been used
alone or in combination. Nonetheless, several studies
suggest that different forms of EM may be both safe
and feasible in ICU patients, including those receiving
mechanical ventilation. Unfortunately, these studies
of EM are mostly single center in design, have limited
external validity and have highly variable control
treatments. In addition, new technology to facilitate
EM such as cycle ergometry, transcutaneous electrical
muscle stimulation and video therapy are increasingly
being used to achieve such EM despite limited
evidence of efficacy. We conclude that although
preliminary low-level evidence suggests that EM in the
ICU is safe, feasible and may yield clinical benefits, EM
is also labor-intensive and requires appropriate staffing
models and equipment. More research is thus required
to identify current standard practice, optimal EM
techniques and appropriate outcome measures before
EM can be introduced into the routine care of critically
ill patients.
Introduction
During critical illness, patients who are immobilized for
more than a few days develop neuromuscular weakness
despite receiving full supportive care, which may include
physical therapy [1-6]. In patients requiring mechanical
*Correspondence: carol.hodgson@monash.edu
1
Australia and New Zealand Intensive Care Research Centre, School of Public
Health & Preventive Medicine, Monash University, The Alfred Centre, 99
Commercial Road, Melbourne, VIC 3004, Australia
Full list of author information is available at the end of the article
© 2010 BioMed Central Ltd © 2013 BioMed Central Ltd
ventilation for longer than 7 days, the incidence of ICU-
acquired (neuromuscular) weakness is reported to be
between 25 and 60% (Table 1) [1,7,8]. Such weakness may
contribute to increased duration of mechanical
ventilation, increased length of stay in the ICU and
hospital, and poor quality of life among survivors [9-11].
These data suggest that any interventions which may
attenuate such weakness and/or shorten the duration of
recovery have the potential to improve both the quality of
life of patients and reduce healthcare costs. Early
mobilization (EM) may represent one such intervention.
In general terms, EM of ICU patients includes the
application of traditional modes of physical therapy at an
earlier stage than and delivered more regularly than
conventional practice, and/or the early use of novel
mobilization techniques (for example, cycle ergometry,
transcutaneous electrical muscle stimulation). EM appears
physiologically logical in patients who would otherwise
remain almost immobile, and may also be a safe and
feasible process. More importantly, EM may also improve
functional recovery, reduce the ICU length of stay,
decrease readmissions to the ICU and even improve
survival [12-16]. Yet limited systematic attention and
analysis has so far been applied to the understanding and
assessment of EM [17]. In this article we aim to define the
concept of EM in comparison with traditional physical
therapy, to review the evidence for its feasibility, safety
and possible efficacy, and to define the research agenda
for its more comprehensive assessment.
Traditional physical therapy
There are international guidelines on the traditional
approach to physical therapy for patients in the ICU.
They include the application of a passive range of
movements and the encouragement of an active range of
movements early in the ICU stay [18]. Attempts at full
active mobilization are often reserved until after the
acute phase of the illness has resolved. In particular, it is
recognized that rehabilitation may not commence until
after ICU discharge, as the patients are viewed as too sick
to participate whilst receiving mechanical ventilation.
These traditional practices are not based on high-quality
evidence and are simply derived from expert opinion.
Despite such opinions, however, practice and attitudes
surrounding physical therapy and mobilization in the
Hodgson et al. Critical Care 2013, 17:207
http://ccforum.com/content/17/1/207
Table 1. Diagnostic criteria for ICU-acquired weakness
Weakness associated with critical illness
Weakness is bilateral, flaccid and involves both proximal and distal muscles
but generally spares the cranial nerves
Medical Research Council sum score <48
Prolonged mechanical ventilation
Other causes of weakness have been excluded
ICU show wide variability worldwide [19], and even
within the same country [20].
The evidence to support the use of passive movements
as part of a program of early mobilization is weak [16].
Such evidence suggests that passive movements may
prevent protein degradation, maintain muscle mass and
alter the inflammatory profile in humans [21,22]. For
example, in 20 subjects with severe sepsis or septic shock
randomized to 30  minutes of predominantly passive
exercise or no intervention, the passive exercise group
preserved fat-free mass, decreased IL-6 and increased
IL-10 levels compared with control patients who lost
7.2% of fat free mass in the first 7  days following
admission to the ICU [23]. Clearly this level of evidence
is minimal and requires further investigation. Clinical
observation, however, suggests that more than simple
passive movement should be done in order to help
preserve muscle strength. EM might represent a better
approach than traditional delayed passive movements.
Before such an intervention can be advocated, however, it
needs to be defined.
What is early mobilization?
EM is the intensification and early application (within the
first 2 to 5 days of critical illness) of the physical therapy
that is administered to critically ill patients (Table 2). EM
may also include additional specific mobilization-enhan-
cing interventions such as active mobilization of patients
requiring mechanical ventilation and the use of novel
techniques such as cycle ergometry and transcutaneous
electrical muscle stimulation (TEMS). In the ICU, EM is
applied with the intention of maintaining or restoring
musculoskeletal strength and function, thereby poten-
tially improving functional, patient-centered outcomes. A
major limitation in the ability to determine the outcomes
following EM is the variety of different techniques
employed, and the lack of standardization and definition
of them across studies (Table 2).
Two randomized, controlled, clinical trials [12,24] and
several observational studies [4,25-31] provide data on
the feasibility and safety of EM as well as preliminary
data on its efficacy in patients dependent on ventilatory
support (Table 2). For instance, in an observational study,
Bailey and colleagues described 1,449 EM interventions
in 103 patients [25]. Overall, 53% of these interventions
Page 2 of 7
included ambulating patients that were dependent on
positive pressure ventilation via an endotracheal tube or
tracheostomy. Only 1% of these EM activities were asso-
ciated with an adverse event. These events included five
episodes of the patient falling to their knees without
injury, three episodes of hypotension to a systolic blood
pressure <90  mmHg, one case of increase in systolic
blood pressure to >200 mmHg, three episodes of oxygen
saturation decreases to <80% and the removal of one
enteral feeding tube. This type of EM treatment was
resourced from within the existing ICU staff structure,
including ICU nurses, technicians, physical therapists
and respiratory therapists.
In a further study, the same group described a before-
and-after cohort study in 104 patients with respiratory
failure who were transferred from another ICU to their
respiratory ICU [28]. Transfer to the EM-based respira-
tory ICU increased the probability of ambulation
(P <0.0001) during the patient’s ICU stay. By multivariate
logistic regression analysis, independent predictors of
increased ambulation were transfer to the respiratory
ICU with a commitment to EM, female gender, absence
of sedatives and lower Acute Physiology and Chronic
Health Evaluation II scores. Eighty-eight percent of
patients survived to hospital discharge with a mean
ambulated distance in the ICU of 200 feet.
In addition to the above work, Schweickert and
colleagues completed a prospective, outcome assessor-
blinded, randomized trial of EM and occupational
therapy in two centers in the USA [12]. In this study,
patients who were mechanically ventilated for <72 hours
and expected to stay ventilated in the next 24 hours were
randomized either to an EM protocol (rapid progression
from passive range of movements to active range of
movements, to bed mobility, to sitting balance, to stand-
ing, to standing transfers and gait re-education during
sedation interruption) or to a control group, which
underwent physical and occupational therapy as pres-
cribed by standard care, typically only after extubation.
This trial found that EM was safe and feasible and that it
was associated with improved functional outcomes as
measured using the Katz Index [32] and independent
walking at hospital discharge. Importantly, patients in the
EM intervention group started physical therapy earlier
(1.5 days vs. 7.3 days, P = 0.0001) and were significantly
more likely to return to functional independence (defined
as being able to wash, dress, groom, eat, transfer from bed
to chair and walk independently) at hospital discharge
(59% vs. 35%, P  =  0.02). This study differed from other
trials because patients were mobilized very early (day  1.5
on average) and the results documented functional
outcomes in a blinded manner. Major adverse events were
rare (one in 498 EM-related events, with no extubations,
falls or change in systolic blood pressure and one episode
Hodgson et al. Critical Care 2013, 17:207 Page 3 of 7
http://ccforum.com/content/17/1/207

Table 2. Observational studies of early mobilization in the ICU

Number of
Study
Bailey and colleagues [25]
Thomsen and colleagues
[28]
Morris and colleagues [27]
Zanni and colleagues [29]
Needham and colleagues
[4]
Bourdin and colleagues
[26]
Kho and colleagues [51]
Genc and colleagues [57]
Leditschke and colleagues
[58]
HR, heart rate; MOS, marching on the spot; MV, mechanical ventilation; OT, occupational therapy; PROM, passive range of movement; PT, physical therapy; RR,
respiratory rate; SBP, systolic blood pressure; SOEOB, sit over edge of bed; SpO2, oxygen saturation measured by pulse oximetry.
patients Inclusion Intervention Primary outcome and key findings
103 Acute respiratory failure Sit on bed, sit on chair and ambulate Early activity events: 1,449 (53% ambulate).
with MV >4 days Adverse events: <1% (fall to the knees with
no injury, SBP >200 or <90 mmHg and
desaturation <80%)
104 Acute respiratory failure Early activity protocol; PROM, SOEOB, Ambulation (increased probability P <0.0001)
with MV >4 days transfer to chair, walk
165 Medical patients with Early activity protocol with four levels of PT (more patients in the protocol group
acute respiratory failure activity: PROM, active resisted exercise received PT versus usual care, 80% vs. 47%,
requiring MV and sitting, SOEOB, and transfer to chair P ≤0.001)
19 Medical patients Individualized stretching, strengthening, Total consultations to PT and OT per patient:
ventilated >4 days balance training and functional activities median 2 (1 to 4). Duration of rehabilitation
(rolling, sitting, standing, walking, (minutes): median 45 (34 to 47)
grooming, bathing)
57 Medical patients Multidiscplinary team to focus on Sedation (benzodiazepam reduced
ventilated >4 days decreased sedation and increased PT P <0.002). Rehabilitation treatments
and OT, particularly with functional (increased P <0.001). Functional mobility
mobility (treatment involving sitting or greater
increased P = 0.03)
20 Medical patients in ICU Chair sitting, tilt table and walking Physiological response: HR and RR
≥7 days and MV ≥2 days increased with sitting, tilting up with arms
unsupported and walking, oxygen saturation
decreased with tilting up arms unsupported
and walking
22 Medical ICU adults Video games Safety (zero adverse events). Feasibility (5%
receiving PT patients receiving PT used video games)
31 Critically ill obese Mobilization; SOEOB, standing, transfer Transient episodes of altered SBP or HR
patients to chair by walking, sitting in the chair in six patients. No deterioration in clinical
status. SpO2 significantly increased after
mobilization
106 Mixed medical–surgical Active mobilization: MOS >30 seconds. Two adverse events in 176 mobilization
ICU Active transfer: transfer bed–chair episodes (1.1%), which were hypotension
against gravity. Passive transfer: passively requiring return to bed and fluid loading
lifted to out of bed (lifter, sling) or vasopressors. Avoidable barriers to
mobilization include femoral lines, sedation
and scheduling procedures

of decreased oxygen saturation <80%). However, in order
to maximize the degree of mobilization, new techniques
are rapidly emerging that can be more easily and perhaps
more safely applied to ventilated supine patients.
Early mobilization using novel techniques
Cycle ergometer
A cycle ergometer is a stationary cycle with an automatic
mechanism that can alter the amount of work performed
by the patient. The cycle can be used passively (no work
from the patient) or actively (Figure 1). Cycle ergometry
has been tested in healthy subjects as part of the space
research program and has been found to preserve thigh
muscle thickness during prolonged immobilization [33].
The method has also been shown to be safe and feasible
in studies during hemodialysis [34] and in patients with
chronic obstructive pulmonary disease [35].
Cycle ergometer-based mobilization in addition to
standard care has now been used as a form of EM in a
single-center randomized trial of 90 critically ill patients,
and compared with standard care alone. In this study,
cycle ergometer-based mobilization improved the median
6-minute walk distance at hospital discharge (196  m vs.
143  m, P  <0.05) [24]. In addition, the mobilization
method was reported to be safe and feasible, with a
median of four cycle sessions completed per week and
the time taken from ergometer set-up to clean-up inclu-
sive reported at 30 to 40  minutes. There were no major
adverse events and only 4% of cycle sessions were stopped
early due to adverse changes in oxygen saturation <90%.
Transcutaneous electrical muscle stimulation
TEMS has been used to preserve muscle mass and
strength in patients with chronic heart failure [36,37] and
Hodgson et al. Critical Care 2013, 17:207
http://ccforum.com/content/17/1/207
Figure 1. A ventilated patient using a cycle ergometer in the ICU.
in patients with chronic obstructive pulmonary disease
[38]. In a recent systematic review, TEMS was found to
improve muscle strength, exercise capacity and disease-
specific health status [39]. TEMS is of particular interest
in the ICU setting because the loss of muscle mass is
rapid and more severe than in other chronic conditions
[40]. In addition, the TEMS technique can be used easily
in immobile sedated patients.
Despite the physiological attractiveness and promise of
TEMS, the randomized controlled trials that have
evaluated the effects of EM by means of TEMS initiated
in the first 7 days of ICU stay have reported conflicting
results [41-45]. Differences in patient selection, the
inclusion or exclusion of patients with sepsis, the appli-
cation of TEMS to heterogeneous populations, and
variable study methodology have all probably contributed
to discrepancies in reported outcomes.
The largest study of TEMS to date investigated 140
critically ill patients and randomly assigned them to
TEMS or standard care [44]. TEMS was conducted daily
for 55 minutes to the lower limb (vastus lateralis, vastus
medialis and peroneous longus muscles). The primary
outcome was ICU-acquired (neuromuscular) weakness
diagnosed using the Medical Research Council score
(<48/60) by two unblinded independent investigators.
The Medical Research Council score was significantly
higher in patients in the TEMS group compared with
those of the control group (58 (33 to 60) vs. 52 (2 to 60)).
However, this study has been criticized for several
reasons [46]. First, measurement of the primary outcome
could only be performed in awake, cooperative patients.
This limitation excluded 39 patients who died and 44
patients who were cognitively impaired from the final
analysis. Accordingly, the intention-to-treat principle
was violated. In the intervention group, data from three
patients were also excluded due to the use of
neuromuscular blockers. Finally, TEMS was applied only
to the lower limb but the Medical Research Council score
Page 4 of 7
reflects upper and lower limb strength. Although it is
theoretically possible that TEMS has systemic effects, the
change in upper limb strength seems unusual [41]. There
was no report of patient tolerance to TEMS. Future
studies should include a report of patient discomfort with
the use of this technique.
Other small randomized controlled trials (n <25 subjects)
have evaluated the effects of TEMS in patients who were
chronically critically ill and requiring mechanical
ventilation for >14 days. Such trials have reported
improvements in muscle mass as measured by ultrasound
[47], muscle strength as assessed using manual muscle
testing (2.2 ± 1.0 vs. 1.3 ± 0.8, P = 0.02) and function as
measured by changes in the number of days required to
transfer from bed to chair (11  ±  2  days vs. 14  ±  2  days,
P  =  0.001) [48]. In this regard, the results of the small
study (n = 24) by Zanotti and colleagues are of particular
interest because improvements in muscle strength were
accompanied by improved function [48]. The inter-
vention protocol, however, included the use of TEMS in
conjunction with a program of active limb exercise in
ventilator-dependent patients with chronic obstructive
pulmonary disease. Their results therefore suggest that
TEMS may act synergistically with active exercise and
thus should not be used in isolation but should rather be
a useful component of a wider-ranging EM protocol
aimed at restoring muscle mass in chronically critically ill
patients. There was no report of patient tolerance to
TEMS.
Despite the above reports, the assessment of efficacy in
small trials remains difficult and investigators are
increasingly focusing on surrogate outcomes that would
justify the conduct of larger phase II studies. Among such
outcomes, muscle layer thickness and muscle cross-
sectional area measured by ultrasound appear to have a
relationship with muscle strength [49,50]. Further
research is required to establish whether these outcomes
are associated with sustained improvement in function
and health-related quality of life and can be reliably used
as surrogates for such clinical outcomes.
Custom-made technological aids
Ambulation is a specific EM technique that is used in the
ICU to improve functional recovery [25,27,29]. Standard
hospital equipment may generally be adequate. When
ambulating a mechanically ventilated patient, however,
the standard equipment may not maximize safety and
effectiveness [40]. For example, some hospitals have had
their own engineers design a custom-made walker for
ventilated patients that incorporates a walking frame on
wheels, an intravenous pole, an oxygen basket and a
platform to support a ventilator, all in a single device
(Figure 2). This type of equipment may improve the safety
of the patient as the nurse and physical therapist have
Hodgson et al. Critical Care 2013, 17:207
http://ccforum.com/content/17/1/207
their hands free of equipment and are able to concentrate
on the patient’s gait, balance and physiological response
to exercise, such as their respiratory rate. There is no
evidence that patients require electrocardiogram moni-
toring during early mobilization.
Video therapies
Among other descriptive papers of novel techniques for
EM in the ICU, the feasibility of Wii and other interactive
video therapies has been described. In an observational,
single-center study, Kho and colleagues investigated the
use of video therapies as a form of EM in critical illness
[51]. Of 410 patients receiving physical therapy, 5% used
video games for balance (52%) and endurance (45%). The
most common games were boxing, bowling and balance
board. No adverse events occurred (95% upper confi-
dence limit for safety event rate: 8.4%). No trials, however,
have compared such interventions with a control group
receiving standard care.
Barriers to early mobilization
Although EM seems intuitively useful and physiologically
logical it can in fact be a complex and effort-intensive
therapy, which is made even more challenging by the
presence of multiple barriers that impede its wider
uptake [30]. Such barriers include inadequate staff to
deliver physical therapy, lack of equipment, concern
regarding patient safety and physiological stability [31],
sedation and ventilation practices, placement of vascular
lines, and the paucity of data on efficacy and health-
economic evaluation to convince clinicians to apply EM
[14].
A key barrier to the delivery of EM is concern about
the safety of the patient [14]. Adverse events may include
the dislodgement of vascular lines, nasogastric tubes and
urinary catheters and, much more importantly, of an
artificial airway, leading to life-threatening hypoxia. To
counter these concerns, however, there is an emerging
body of data suggesting that EM does not impose an
increased risk to patients if it is performed with
appropriately trained staff [4,12,24,25,27,28,30]. In
several studies conducted in US centers, EM involved a
mobilization team of three ICU clinicians, including a
physical therapist, a nurse and an occupational therapist
or an assistant [25,27,28]. In addition, patients were
carefully evaluated holistically prior to undertaking EM
with a comprehensive assessment of age, level of fitness
prior to ICU admission, presenting condition, tolerance
of other interventions and the amount of ventilatory and
cardiac support required prior to EM.
EM is feasible only if the patient is awake and co-
operative [52] and therefore the use of sedation needs to
be minimized to facilitate EM [53]. The importance of
interactions between the degree of sedation and the
Page 5 of 7
Figure 2. Custom-made walker for ventilated patients. The walker
incorporates a walking frame on wheels, intravenous pole, oxygen
basket and platform to support a ventilator, all in a single device.
ability to apply EM has been highlighted in several
publications [30,53]. Other key factors that appear to be
associated with successful EM include adequate pain
management and early recognition and management of
delirium [13,54-56].
An additional consideration is the availability of
sufficient staff and equipment to facilitate EM. Physical
therapists should be an integral part of the inter-
disciplinary team in the ICU involved in the implemen-
tation of EM. Having at least one ICU nurse available is
also important (Figure  3). In the USA, a respiratory
therapist would also be included to disconnect the
ventilator and assist with a portable ventilator [15]. The
need for such complex multiskilled personnel with
sufficient training in EM and the need for appropriate
equipment may be the major barrier to the imple-
mentation of EM in most ICUs worldwide.
Early mobilization research agenda
International differences in staff availability result in
heterogeneous research questions in relation to EM in
different countries. In American studies, for example,
research has concentrated on providing information to
justify appropriate resources for physical therapy input in
ICUs [4]. In contrast, in Europe and Australia physical
therapy is generally considered part of standard manage-
ment. Two national surveys, however, have reported a
striking degree of variability between institutions within
the same country in terms of referral to physical therapy
during critical illness, staff ratios and frequency of such
therapy [19,20]. This variability in practice underscores
the importance of carefully defining and understanding
usual care prior to undertaking any interventional studies
Hodgson et al. Critical Care 2013, 17:207
http://ccforum.com/content/17/1/207
Figure 3. A ventilated patient walking with assistance of physical
therapists and a trolley.
to evaluate the efficacy and safety of EM in different
jurisdictions. The variability also highlights the limited
external validity of single-center studies.
Key research questions
Standard mobilization practice in ICUs nationally and
internationally remains poorly defined. Until standard
mobilization is clearly defined and measured in multi-
center studies it is impossible to conduct studies of any
EM interventions that are relevant to modern ICU
treatment, have external validity, and provide sufficient
treatment separation. There may be limitations to
establishing a true, ethical control group to establish the
effect of EM, especially in those countries where
physiotherapy practice already includes elements of EM.
The typical functional outcomes of candidate patients
who survive and are treated with standard care also need
to be defined. Once baseline practice and functional out-
comes are established in multicenter prospective cohort
studies, then multicenter pilot studies of a candidate EM
intervention can be tested for separation and contami-
nation. In addition, several potential relevant outcomes
(muscle thickness, muscle strength for different muscle
groups, functional independence) must also be assessed
as outcome measures for EM interventions and their
relationships with each other understood in order to
power future larger studies of these interventions.
Conclusion
ICU survivors recovering from a prolonged illness often
have muscle weakness and major functional impairment.
Early mobilization is a physiologically logical candidate
intervention to attenuate such weakness. Observational
studies and initial small randomized trials evaluating EM
suggest safety and feasibility. These studies also suggest
Page 6 of 7
that EM has the potential to improve functional
outcomes in survivors. Unfortunately, such studies are
mostly single center in design and carry limited external
validity. Further trials to investigate the potential benefits
of EM and the best techniques to maximize its efficacy
are warranted but require careful consideration of
standard practice, optimal treatment strategies and
outcome measures.
Abbreviations
EM, early mobilization; IL, interleukin; TEMS, transcutaneous electrical muscle
stimulation.
Competing interests
The authors declare that they have no competing interests.
Acknowedgements
Written consent for publication was obtained by the patients.
Author details
1
Australia and New Zealand Intensive Care Research Centre, School of Public
Health & Preventive Medicine, Monash University, The Alfred Centre, 99
Commercial Road, Melbourne, VIC, Australia, 3004. 2The Alfred, Melbourne,
Commercial Rd Prahran, VIC, Australia, 3181. 3Austin Health, 145 Studley Rd,
Heidelberg, VIC, Australia, 3084. 4University of Melbourne, Grattan St Parkville,
Melbourne, VIC, Australia, 3010. 5Curtin University, GPO Box U1987, Perth,
Western Australia, 6845. 6Royal Perth Hospital, 197 Wellington St, Perth, WA,
Australia, 6000. 7The St George Hospital, Gray St, Kogarah, NSW, Australia, 2217.
8
The University of New South Wales, High St, Kensington, NSW, Australia, 2052.
9
The George Institute For Global Health, Level 13, 321 Kent Street, Sydney,
NSW, Australia, 2000.
Published: 28 February 2012
References
1. Saxena MK, Hodgson CL: Intensive care unit acquired weakness. Anaesth
Intensive Care Med 2012, 13:145-147.
2. Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO,
Ross A, Dixon L, Leach S, Haponik E: Receiving early mobility during an
intensive care unit admission is a predictor of improved outcomes in
acute respiratory failure. Am J Med Sci 2011, 341:373-377.
3. Needham DM: Mobilizing patients in the intensive care unit: improving
neuromuscular weakness and physical function. JAMA 2008, 300:1685-1690.
4. Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB,
Brower RG, Fan E: Early physical medicine and rehabilitation for patients
with acute respiratory failure: a quality improvement project. Arch Phys
Med Rehabil 2010, 91:536-542.
5. Griffiths RD, Hall JB: Intensive care unit-acquired weakness. Crit Care Med
2010, 38:779-787.
6. Maramattom BV, Wijdicks EF: Acute neuromuscular weakness in the
intensive care unit. Crit Care Med 2006, 34:2835-2841.
7. de Jonghe B, Lacherade JC, Sharshar T, Outin H: Intensive care unit-acquired
weakness: risk factors and prevention. Crit Care Med 2009,
37(10 Suppl):S309-S315.
8. Nordon-Craft A, Moss M, Quan D, Schenkman M: Intensive care unit-
acquired weakness. J Neuro Phys Ther 2011, 35:133-140.
9. Herridge MS: Long-term outcomes after critical illness: past, present,
future. Curr Opin Crit Care 2007, 13:473-475.
10. Herridge MS: Legacy of intensive care unit-acquired weakness. Crit Care
Med 2009, 37(10 Suppl):S457-S461.
11. Rubenfeld GD, Herridge MS: Epidemiology and outcomes of acute lung
injury. Chest 2007, 131:554-562.
12. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL,
Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA,Bowman A, Barr R,
McCallister KE, Hall JB, Kress JP: Early physical and occupational therapy in
mechanically ventilated, critically ill patients: a randomised controlled
trial. Lancet 2009, 373:1874-1882.
13. Morandi A, Brummel NE, Ely EW: Sedation, delirium and mechanical
ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care 2011, 17:43-49.
Hodgson et al. Critical Care 2013, 17:207
http://ccforum.com/content/17/1/207
14. Morris PE: Moving our critically ill patients: mobility barriers and benefits.
Crit Care Clin 2007, 23:1-20.
15. Perme C, Chandrashekar R: Early mobility and walking program for patients
in intensive care units: creating a standard of care. Am J Crit Care 2009,
18:212-221.
16. O’Connor ED, Walsham J: Should we mobilise critically ill patients?
A review. Crit Care Resusc 2009, 11:290-300.
17. Adler J, Malone D: Early mobilization in the intensive care unit: a systematic
review. Cardiopulm Phys Ther J 2012, 23:5-13.
18. Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, Schonhofer B,
Stiller K, van de Leur H, Vincent JL: Physiotherapy for adult patients with
critical illness: recommendations of the European Respiratory Society and
European Society of Intensive Care Medicine Task Force on Physiotherapy
for Critically Ill Patients. Intensive Care Med 2008, 34:1188-1199.
19. Norrenberg M, Vincent JL: A profile of European intensive care unit
physiotherapists. European Society of Intensive Care Medicine. Intensive
Care Med 2000, 26:988-994.
20. Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M: Physical therapy
utilization in intensive care units: results from a national survey. Crit Care
Med 2009, 37:561-568.
21. Griffiths RD, Palmer TE, Helliwell T, P. M, MacMillan RR: Effect of passive
stretching on the wasting of muscle in the critically ill. Nutrition 1995,
1:428-432.
22. Paratz JD, Kayambu G: Early exercise and attenuation of myopathy in
patient with sepsis in ICU. Phys Ther Rev 2011, 16:58-65.
23. Kayambu G, Boots RJ, Paratz JD: Early rehabilitation in sepsis: a prospective
randomised controlled trial investigating functional and physiological
outcomes The i-PERFORM Trial (Protocol Article). BMC Anesthesiol 2011,
11:21.
24. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, Hermans
G, Decramer M, Gosselink R: Early exercise in critically ill patients enhances
short-term functional recovery. Crit Care Med 2009, 37:2499-2505.
25. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K,
Rodriquez L, Hopkins RO: Early activity is feasible and safe in respiratory
failure patients. Crit Care Med 2007, 35:139-145.
26. Bourdin G, Barbier J, Burle JF, Durante G, Passant S, Vincent B, Badet M, Bayle F,
Richard JC, Guerin C: The feasibility of early physical activity in intensive
care unit patients: a prospective observational one-center study. Respir
Care 2010, 55:400-407.
27. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A,
Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small
R, Hite RD, Haponik E: Early intensive care unit mobility therapy in the
treatment of acute respiratory failure. Crit Care Med 2008, 36:2238-2243.
28. Thomsen GE, Snow GL, Rodriguez L, Hopkins RO: Patients with respiratory
failure increase ambulation after transfer to an intensive care unit where
early activity is a priority. Crit Care Med 2008, 36:1119-1124.
29. Zanni JM, Korupolu R, Fan E, Pradhan P, Janjua K, Palmer JB, Brower RG,
Needham DM: Rehabilitation therapy and outcomes in acute respiratory
failure: an observational pilot project. J Crit Care 2010, 25:254-262.
30. Leditschke A, Green M, Irvine J, Bissett B, Mitchell I: What are the barriers to
mobilizing intensive care patients? Cardiopulm Phys Ther J 2012, 23:26-29.
31. Genc A, Ozyurek S, Koca U, Gunerli A: Respiratory and hemodynamic
responses to mobilzation of critically ill obese patients. Cardiopulm Phys
Ther J 2012, 23:14-18.
32. Brorsson B, Asberg KH: Katz index of independence in ADL. Reliability and
validity in short-term care. Scand J Rehabil Med 1984, 16:125-132.
33. Ellis S, Kirby LC, Greenleaf JE: Lower extremity muscle thickness during
30-day 6 degrees head-down bed rest with isotonic and isokinetic
exercise training. Aviat Space Environ Med 1993, 64:1011-1015.
34. Moug SJ, Grant S, Creed G, Boulton Jones M: Exercise during haemodialysis:
West of Scotland pilot study. Scott Med J 2004, 49:14-17.
35. Larson JL, Covey MK, Wirtz SE, Berry JK, Alex CG, Langbein WE, Edwards L:
Cycle ergometer and inspiratory muscle training in chronic obstructive
pulmonary disease. Am J Respir Crit Care Med 1999, 160:500-507.
36. Sbruzzi G, Schaan BD, Pimentel GL, Signori LU, Da Silva AN, Oshiro MS,
Irigoyen MC, Plentz RD: Effects of low frequency functional electrical
stimulation with 15 and 50 Hz on muscle strength in heart failure patients.
Disabil Rehabil 2011, 33:486-493.
37. Quittan M, Wiesinger GF, Sturm B, Puig S, Mayr W, Sochor A, Paternostro T,
Resch KL, Pacher R, Fialka-Moser V: Improvement of thigh muscles by
neuromuscular electrical stimulation in patients with refractory heart
Page 7 of 7
failure: a single-blind, randomized, controlled trial. Am J Phys Med Rehabil
2001, 80:206-214.
38. Neder JA, Sword D, Ward SA, Mackay E, Cochrane LM, Clark CJ: Home based
neuromuscular electrical stimulation as a new rehabilitative strategy for
severely disabled patients with chronic obstructive pulmonary disease
(COPD). Thorax 2001, 57:33-37.
39. Sillen MJ, Speksnijder CM, Eterman RM, Janssen PP, Wagers SS, Wouters EF,
Uszko-Lencer NH, Spruit MA: Effects of neuromuscular electrical
stimulation of muscles of ambulation in patients with chronic heart failure
or COPD: a systematic review of the English-language literature. Chest
2009, 136:44-61.
40. Needham DM, Truong AD, Fan E: Technology to enhance physical
rehabilitation of critically ill patients. Crit Care Med 2009, 37(10
Suppl):S436-S441.
41. Ali NA: Have we found the prevention for intensive care unit-acquired
paresis? Crit Care 2010, 14:160.
42. Gerovasili V, Stefanidis K, Vitzilaios K, Karatzanos E, Politis P, Koroneos A,
Chatzimichail A, Routsi C, Roussos C, Nanas S: Electrical muscle stimulation
preserves the muscle mass of critically ill patients: a randomized study. Crit
Care 2009, 13:R161.
43. Gerovasili V, Tripodaki E, Karatzanos E, Pitsolis T, Markaki V, Zervakis D, Routsi
C, Roussos C, Nanas S: Short-term systemic effect of electrical muscle
stimulation in critically ill patients. Chest 2009, 136:1249-1256.
44. Routsi C, Gerovasili V, Vasileiadis I, Karatzanos E, Pitsolis T, Tripodaki E, Markaki
V, Zervakis D, Nanas S: Electrical muscle stimulation prevents critical illness
polyneuromyopathy: a randomized parallel intervention trial. Crit Care
2010, 14R74.
45. Rodriguez PO, Setten M, Maskin LP, Bonelli I, Vidomlansky SR, Attie S, Frosiani
SL, Kozima S, Valentini R: Muscle weakness in septic patients requiring
mechanical ventilation: protective effect of transcutaneous
neuromuscular electrical stimulation. J Crit Care 2012, 27:e311-e318.
46. Rodriguez PO, Setten M, Valentini R: Electrical muscle stimulation for
prevention of critical illness polyneuropathy. Crit Care 2010, 14:428.
47. Gruther W, Kainberger F, Fialka-Moser V, Paternostro-Sluga T, Quittan M, Spiss
C, Crevenna R: Effects of neuromuscular electrical stimulation on muscle
layer thickness of knee extensor muscles in intensive care unit patients: a
pilot study. J Rehabil Med 2010, 42:593-597.
48. Zanotti E, Felicetti G, Maini M, Fracchia C: Peripheral muscle strength
training in bed-bound patients with COPD receiving mechanical
ventilation. Chest 2003, 124:292-296.
49. Chi-Fishman G, Hicks JE, Cintas HM, Sonies BC, Gerber LH: Ultrasound
imaging distinguishes between normal and weak muscle. Arch Phys Med
Rehabil 2004, 85:980-986.
50. Seymour JM, Ward K, Sidhu PS, Puthucheary Z, Steier J, Jolley CJ, Rafferty G,
Polkey MI, Moxham J: Ultrasound measurement of rectus femoris cross-
sectional area and the relationship with quadriceps strength in COPD.
Thorax 2009, 64:418-423.
51. Kho ME, Damluji A, Zanni JM, Needham DM: Feasibility and observed safety
of interactive video games for physical rehabilitation in the intensive care
unit: a case series. J Crit Care 2012, 27:e211-e216.
52. Hopkins RO, Spuhler VJ: Strategies for promoting early activity in critically
ill mechanically ventilated patients. AACN Adv Crit Care 2009, 20:277-289.
53. Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS: Reducing
iatrogenic risks: ICU-acquired delirium and weakness – crossing the
quality chasm. Chest 2010, 138:1224-1233.
54. Bigatello LM, Citerio G: The long-lasting damage of delirium: another
burden to intensive care unit survivors. Crit Care Med 2012, 40:319-320.
55. Morandi A, Jackson JC: Delirium in the intensive care unit: a review. Neurol
Clin 2011, 29:749-763.
56. Page V, Gough K: Management of delirium in the intensive care unit. Br J
Hosp Med (Lond) 2010, 71:372-376.
57. Genc A, Ozyurek S, Koca U, Gunerli A: Respiratory and hemodynamic
responses to mobilization of critically ill obese patients. Cardiopulm Phys
Ther J 2012, 23:14-18.
58. Leditschke IA, Green M, Irvine J, Bissett B, Mitchell IA: What are the barriers to
mobilizing intensive care patients? Cardiopulm Phys Ther J 2012, 23:26-29.
doi:10.1186/cc11820
Cite this article as: Hodgson CL, et al.: Clinical review: Early patient
mobilization in the ICU. Critical Care 2013, 17:207.